Anal incontinence

People want to think as little as possible about conditions such as anal incontinence. Just the thought of not being able to control how and when you empty your bowels is alienating and uncomfortable.

On top of that, there can quickly be a social stigma attached to not being able to hold back wind and stool in a controlled manner. This is because strangers rarely think that it could be a medical condition. In fact, it is much easier to insinuate that it is due to a lack of hygiene or manners.

In general, incontinence always describes the leakage of a sphincter muscle. This can affect both the urinary bladder and the large intestine outlet. In the case of anal incontinence, depending on the degree of severity, there is uncontrolled discharge of diapers, thin stools or even the entire contents of the bowel.

The disease is more common than one might think. Between one and three percent of the population suffers from fecal incontinence, with the incidence increasing dramatically with age. In younger people, temporary anal incontinence can occur mainly due to diarrhoeal diseases.

The causes of anal incontinence can be very different. That is why it is always important that a detailed diagnosis is carried out. In addition to the primary causes of anal incontinence mentioned below, there are of course a whole range of diseases that lead to anal incontinence. These include, for example, various intestinal diseases that severely restrict bowel movements.

Injury or disease of the nervous system

Damage to nerves in the brain, spinal cord or peripheral nervous system in particular can impair the function of the anal sphincter. Neurological diseases such as Alzheimer's disease, multiple sclerosis and a brain tumour, as well as strokes are possible causes.

In addition, disorders in the transmission of information can cause anal incontinence. This includes not only paraplegia, but also other congenital and acquired neurological diseases that prevent the conduction of impulses in the spinal cord.

But it is not only the failure of the nerves that control the sphincter that can lead to anal incontinence. A disturbance in sensory perception can also result in incontinence. Due to the lack of input, the patient no longer knows when the bowel needs to be emptied. Once the bowel is filled to a certain level, spontaneous emptying occurs, which can no longer be consciously influenced.

Destruction of the musculature

In rare cases, weakness of the sphincter muscle itself can also lead to anal incontinence. Then the muscle is simply too weak to withstand the pressure in the bowel.

Often there is involvement of the pelvic floor muscles. When this weakens, or sags, the bowel can no longer close tightly, resulting in at least mild anal incontinence. With age, almost everyone experiences a weakening of the pelvic floor muscles, which may explain the frequent occurrence of the condition with increasing age.

Anal incontinence is divided into different degrees of severity depending on its severity.

• Perfect continence
• Good continence: There is only a slight impairment of continence, which mainly consists of the involuntary release of diapers.
• Moderate incontinence: In addition to the uncontrolled release of diapers, there is also occasional release of thin stool.
• Severe incontinence: In the case of severe incontinence, not only thin liquid stool, but occasionally also solid and formed stool is involuntarily passed.
• Total incontinence: In the most severe form of anal incontinence, the patient no longer has any control at all over when the bowel is emptied.

At the beginning of the diagnosis of anal incontinence is a detailed anamnesis. Even if it is unpleasant to talk about it, above all the beginning of the complaints, the frequency of bowel movements and their nature and the circumstances of the involuntary bowel movements must be described in detail. Sometimes it can be useful to keep a stool diary for a few days to give a better picture of the symptoms.

Physical examination

This is followed by a physical examination with inspection and palpation of the anal region. A rectal examination must also be done to evaluate the sphincter function, and to get further clues about the cause.

To get better data, manometric measurements and rectoscopies may also be performed. These examinations are uncomfortable but usually painless.

Imaging procedures

If the cause is still not clear or to rule out other causes, imaging procedures are often still used. This includes not only ultrasound, but also X-ray imaging. This can be done with or without X-ray contrast medium. In certain cases, computer tomography also makes sense.

The means of diagnosis are advancing all the time, so that today it is even possible to observe the voiding process precisely with certain procedures in order to be able to determine the cause of faecal incontinence beyond doubt. Since these diagnostic procedures are very complex, it is always necessary to assess exactly which means should be used for diagnosis.

Of course, the therapy depends on the underlying cause. Therefore, no therapy measure can be described that applies to all patients. But there are general behavioural measures that can be helpful in getting faecal incontinence under control.

Optimising bowel behaviour

Getting into the habit of having bowel movements at the same time every day can be extremely helpful. This small change can completely cure at least mild incontinence in many cases. Regular bowel movements can also be supported with suppositories, especially in the first few weeks. After two to three weeks, however, the bowel should have become accustomed to this and it should work perfectly.

Optimising the diet

Of course, the diet should also be optimised. This includes a balanced and healthy diet. Depending on the consistency of the stool, certain foods should be avoided. For example, if the stool is thin, an attempt should be made to change the diet so that a firm stool can be achieved.

Biofeedback therapy for nerve damage

If there is underlying nerve damage, residual nerve activity can be increased by training the sphincter and pelvic floor muscles. In addition, biofeedback therapy can be performed with electrical aids.

Drug therapy

Not only when inflammation of the bowel or other underlying diseases are present, can also be treated with medication. This includes not only the therapy of diarrhea, but also the regulation of bowel emptying.

Surgical measures

If the defect of the sphincter muscle is the cause of anal incontinence, it can be reconstructed surgically. This often involves taking part of a muscle from the thigh and placing it around the sphincter to strengthen it. Sometimes an inflatable ring can be placed around the muscle, which can be inflated via a balloon in the pubic area to achieve continence.

These are sometimes very complex procedures that can only be performed in specialized clinics. In some cases, however, they can increase the quality of life enormously, which is why these options should not be forgotten.

Incontinence aids

If faecal incontinence cannot be satisfactorily treated, a number of aids are available today to make everyday life with incontinence easier. These naturally also have the aim of enabling a normal social life. A distinction is made between absorbent aids (pads, pants, diapers) and other aids (adhesive bags, anal tampons).

Sometimes the patient decides together with the doctor that a therapy would be too costly or too risky. This is because mild anal incontinence in particular can be treated very well with the available incontinence aids.

The prognosis for the treatment of anal incontinence is very good. Most of the time, a very good success can already be achieved with changes in behaviour. Otherwise, surgery can still be performed if this would greatly increase the quality of life.

Of course, it is always necessary to try to eliminate the particular cause, and not just treat the symptom. Thus the treatment of anal incontinence is always very individual, and only rarely can the experience of one patient be applied exactly to another. This is because the cause and management of faecal incontinence varies greatly from person to person.